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1436A 1437A
_.... .,_ .--- - -.. .... ----. ... .., --...,...__.... ... . ......_�. .....______.._. . _. . ...... .... _. .._ WORKERS'COMPENSATION DECLARATION . ��+ .�: � ~. � ' : -;'� . ' - ' �� � I hereby aHirm thoi I hove a certifimie oF�o��e�,�o se,f -- �-� �- �APPLICATI�ONJ�F4R���BUILDING �PERMIT �� insure,or a cerlifimte of Workeri Campensation Insurance, . .. -.. ...._. . . _. . . __ _ . _ ._ ... . ..... ... . . n certifir' cp . qrr�.,ck'Dyt rep� e�i LR C.� . . �- COUNTY OF LOS ANGELES BUILDING AND SAFETY �I cy o. t IV ompany (���� I auuo�Nc a Certified copy is hereby iurnisi+e�I G.I�% G FOR APPLICANT i0 FILL IN ADDRESS .2�G Jf . (� �Certified copy is filed with the count building inspec- - - BUItDING23 � JS � � Mx'tion departmenl.�� '� ' ADDRESS .f�� , : . .. � �. ..... . . .. . __ . _. .. _. . . Date Applicant - v LP IOCAIItt � � � ' ' � ERTIFI ATE OF EXEMPTION FROM WORKERS' ---��- - -� -- '�--- ����- � NO.OF BiDGS:----• �- - - nIEAREST- . . �-,,,..�-. --_ --. � ��� " � -COMPENSATION INSURANCE� . SIZE OF LO7 NOW ON LOT CRO55 ST. (This section need not be completed if ihe permit is for one � � - � � � � � ASSESSOR. �-- hundred dollars(5100)or less.). - , , TRAR BLOCK LOi NO. µqP gppK� ' PAGE PARCEL . � ,E�. G / � NE ,�wP 1 ce�fify that in the performonce of��he work for whlch Ihis OWNER - - N :J`b ��� � 0�-,3- 3��r •� � '} � permit is issued,I shall nof employ ony person in any manner qppRE55- ��V CJ �E��A� � a .' .' _ ' "_ . .'..___.._._ ._. s CONDITIONS � ' � , . . �u so as 10 become suLijeU ta Ihe Workers'Compensalion Laws. ,. � .- . ; •. �.. . � - --- --�- -. . . . . . . . . . . ._ CITY._.. _ _' . ..ZIP.. . ... ._" . , � OC Da�e � Applimni� � ARCHITECT OR TEL. �O NOTICE TO APPLICAN7:•If, aher making this Cerlifico�e of D151RICT._ GROUP C�NST . . -Zp� PROCESSE�BY. . .� I � Eaemption,�you shauld become subject to ih0 WOII(er5' - ENGMEER NO. � Compensation provisions of tha Lobor Code,you mus�forth- qODRE55 // � �-� �- - - N wilh comp�Y p SionS of ihi5 permil ShaII be - � CONTRACTOR - � E�� D 1 STAT�STICAL MSSIFICATION th such rovi i deemed revoked. .�, .� � . � .. ..� '� APT. CONDO. Z IICENSED CONTRACTORS�ECLARATION� MSS NO. �'2'���DVJELL:UNiTS I I hereby offirm Ihot I om licensed under provisio�s oi Chapter 9 ADDRES . ��R�P (commencirg wi�h$eciion 7000)of�ivision 3 of the Business and . . ... . .. . .__. - IIC: -----��-- . Profess�ons Code,and my license is in full force ond eifeU. CI S CInSS �--BK� '-�- --� VALIOATION � � '�� � . . Sp.F. NO.OF NO.OF _. CHECK . ' � ' nse NGr'}�bei iC.C�o55 ' SIZE STORIES FAMIIIES ONE - : � ,, .`� � ��- �-- � VAWATION_._: DESCRIPTIDN OF WORK NEW-��a f : 1 4'a 6 A, .. . � Commctor � me � ' �G�: .� J ADO � 2 3 ❑I am eaempt under Sec. � -- ----- - -- - ------ '- ��� • • •�• . . .. . ALTER � •� 1 8.8P.C.for this reason . RE7niR � ��_�" -" . " ' � • •C 7.6 3�� � �Dale: E%ST�ING BLDG. DEMOL ❑ . . ._.• • •2 Z 6 3 c=i ' s�y�awre . _- avaicaNr J I NO ^ FINAL� O 7,1 8—8 5 OWNER-BUIIDER DECLARATION _ ,_ PRiNT �-DATE�-�7-�"�„=- � - �� "...... . ... ..... 1 hereby affi�m Ihm I am ezempt from the Controttor's License - — � , _ law for the following reasan(Sedion 7031.5,Business and /DDRE55 FlNA� '- ' , � ' .� ... .. -.: : . . � , . . �/� .. .. .. _ ... . . . . .- ----.. Pfofe55i0�s COdo�: ' ' ' - �'- "� ' ' PkE EN1 8y Y` ��\� .. BUiIDING � I, as owner of iha property, or my employees wi�h nooRess . �1 4 a 7 A- woges as�heir sole tompensotian,will do�he work ond � � -. �� -� � � � tha structure is not iMended or offered for sala(Secflon � '� � - 7044,BuslnezsandProfessionsCode). - � ' � MOVING-�� �-- ��' � � TEL.' ' '- ! ' � �� �� ��� � ��i r• C v 3/3.3' � I,os owner oi Ihe property,am eadusively contmUing �ONTRACfOR NO. , r.• •4�O O wifh Iicensed coniroc�ors to cons�ruct rhe project(Seo-- ppoacss � tion 7044,Business and Mofessionz Code). ' � � -�- '-- CONSTRUCTION LENDING AGENCY . ....... . . sc�sacK' 'rnaD� HwY 101Ap OTP LCNEFR M- 'WIDTH ...... . ......... ''"" ' � - .. '. '� • •/�`Z O O c: � I hereby af(irm�hat�here is a construttion lending ogency fa ppONT o 7,1 8=8 5 � ihe performonce of�he work for which this permit is issued � - v.t. � � ---� -- -- -- ��- - ---�� � -�� � �� ---- -� - � - - - -- �- - - � - � ($eC.3097,Civ.C.). SIDE .. .. : m . . . . . _ _ _ . ..._. ... __.._ ... P.L .. . _. . . � . ..._._ . . .. . � Lender's Name IDMH Ref.N $ ._ ...__ . _'., .. P.QFeeS.. •2 •-�� .'. PermitFee �z•� . .. .. . _ .. . � . . . _ _..__ ' . - lendei s Address �� • > �o. sv � _ 1 certify that i have�eod�his applim�ion and s�ata thot the .__._ - - - - hsva�c�Fee-- �DMA PiC M-- - - � - - , � . . ... ._ . . . . . . .. . � obove informalian is corrttf.I ag�ea fo comply with oll Counfy Invesiigation Fee �[ s � � g ordinances and Slate lows relating to boilding construUion, ,_ ,_. ,_ _._.._. __..__ Taol Fee- —T�r� v IDMA Verm:M- � . .__ . . _ _..__ . _ - . u and hereby auihoriza representotives of this County to enfer � u n ihe obr�/-mentioned properly for({�'spetlion purposes. a � ,[��Sj��� !��_Kl 1 N VY�('l[� 7 f'�l�5 SEE REYERSE FOR EXPLAN�70RY LANGV�GE � � �� � �- Signature of APPhmnt or Agenr - � - pcte . 1 . . . ' -. -.__ _ ____. _-______ _ ..._.._. _ ______ _._. ..� � __. _ . .. .. Z 'o - o • � _. ,,., ..� o G� � ' A ° ^ N N O- � n' v O � q - p -p O O � n N � �O O � ::� '� m P 7 n. 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